CMS’s E/M reimbursement cuts hurt physicians and patients

August 7, 2018

While CMS says it aims to allow doctors more time with patients with less documentation, its proposed E/M changes simply don’t achieve that goal.

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CMS is proposing changing documentation and payment for evaluation and management (E/M) coding as part of its “Patients over Paperwork” initiative.

In brief, CMS proposes simplifying documentation guidelines and collapsing E/M codes higher than 99211 and 99201 into one code with a blended rate of reimbursement. For a more complete, but brief, outline of this proposal on the CMS website and search "patients over paper".. The goal of allowing doctors to spend more time with patients and less with documentation is the spoken outcome, but this proposal will result in anything but achieving that goal.

The documentation which has been chosen for elimination/simplification is the easiest and least time consuming for physicians to perform with the electronic measures we have been encouraged to adopt. Having adjusted our EHRs to accomplish the E/M requirements in place for the past 20 years, we are copying information and opening fields of previous data with a few clicks. In other words, physicians have gotten good at this. Calculating about 15 seconds per patient, changing this documentation would save about 10 physician hours annually.

The ever-increasing stress of our electronic time comes from listening to webinars, spending time working with our EHR vendors to create and click new and recognizable fields, and performing other IT gymnastics to meet CMS’s Merit-based Incentive Payment System (MIPS) requirements. We have been called upon to learn, implement, and pay to do all of this with our own time and resources, and we are doing our best to comply.

Perhaps because of the extra time CMS says will be generated by this proposal, or because they will no longer be able to track how much work we are doing for our patients, CMS has proposed a blended rate of reimbursement for all but nurse visits. This will greatly disadvantage providers who spend time caring for patients requiring complex care. Our practice serves a large Medicare population with problems which are increasingly time consuming and very often qualify for 99204 and 99214 levels of care. The proposed new blended payment would result in at least a 3-percent to 5-percent cut in reimbursement. CMS proposes an additional code that physicians can use to add to the blended rate which would result in $5 more for primary care providers and an additional $15 for specialty providers.

According to the federal document which explains CMS’s reasoning for the additional primary care code, it was created to cover “additional resource costs and maintain the work as budget neutral” for “visit complexity inherent to the evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services.” It is both frightening and demeaning to discover that CMS believes the aforementioned care to be worth less for primary care providers than for specialists, and less than the cost of a Starbucks coffee.

CMS’s goal is to promote better, less expensive care for patients and to encourage providers to take on risk for patient care. This care must take place in some form of a primary care office setting as opposed to the overuse of specialty, emergency department, and hospital care.

A 3-percent to 5-percent decrease in Medicare reimbursement will result in less time available for each patient because there will need to be more patients seen every day to offset the financial loss. Visits will need to be shorter and will cover fewer concerns with patients returning more frequently. More patients will end up in EDs and hospitals.

There will be less money available for support staff and for new staff such as chronic care managers and mental health providers whom we are being encouraged to hire to improve the quality and broaden the level of our care.

There will be an increase in referrals to specialists to handle more complicated problems. With this increase in the use of referrals and hospitals, providers who were working to decrease resource utilization will be reluctant to assume financial risk for their patients’ care.

Office physicians who depend on reimbursement from E/M codes will be disproportionately affected in comparison to specialists who are paid higher rates to perform procedures.

For all the above reasons, we do not favor the adoption of this policy. If it is adopted in some form, the blended reimbursement rates should be within $1 to$2 of the current rates for 99204 and 99214 without the add-on $5 and $15 codes. We will already be giving up the higher reimbursement rates for 99205 and 99215.

As discussed, expenses for physicians in terms of time and resources is increasing. If CMS is to be the agent for beneficial change for Medicare patients and desires respect and cooperation from the practicing physician community, its proposals must be at least cost neutral.

Lorraine Nardi-Gross, MD, is an internal medicine specialist in the lower Hudson Valley, N.Y.